From believers to skeptics: Latent class analysis of COVID‐19 protective practices and perceptions among agricultural community members

Abstract Purpose This cross‐sectional study aimed to identify homogenous groups of agricultural producers and stakeholders based on their perceptions of effectiveness and use of COVID‐19 protective behaviors. Methods We conducted an online survey of agricultural producers and stakeholders through Qualtrics. Participants responded to 7 statements about COVID‐19 protective behavior effectiveness and 7 statements about participation in COVID‐19 protective behaviors in the previous 2 weeks. These statements included handwashing, disinfecting, refraining from touching one's face, covering one's face when coughing/sneezing, staying at home, social distancing, and wearing a face mask. Additional survey sections included demographics and health history. We performed separate latent class analysis (LCA) to identify clusters of agricultural producers’ and stakeholders’ perceptions and participation in COVID‐19‐related protective behaviors based on their pattern of responses. Findings Based on LCA, participants were distributed as universal believers (33%), social believers (16%), personal believers (26%), moderate believers (17%), and social skeptics (85%) of effectiveness and as low (15%), moderate (40%), and high (45%) adherents of COVID‐19 protective behaviors. Those who were female, older, or had underlying health conditions were more likely to be universal believers and highly adherent. High adherence was also more likely among those who lived in urban areas or were not self‐employed. Conclusions Results suggest that groups of agricultural producers and stakeholders based on perception of effectiveness and participation in COVID‐19 protective behaviors are associated with demographic and health characteristics. Public health campaigns that increase or maintain motivation to comply with protective behaviors should be developed and implemented specific for agricultural populations.


INTRODUCTION
The COVID-19 pandemic as a public health emergency has required mass engagement in protective behaviors, such as staying at home, social distancing, wearing face masks, and frequent handwashing, in order to curb the spread of the potentially fatal virus. 1 However, COVID-19 risks have not been distributed evenly across the population. Lower geographic density and isolation common to rural areas may have initially reduced risk of COVID-19 in rural areas, by March 2021 COVID-19 spread was higher rural areas. 2,3 COVID-19 vaccination rates have been lower in rural counties, and within rural counties, lowest among counties that are farming dependent. 4 Additionally, people in occupations deemed essential were, at times, unable to engage in some protective behaviors based on the nature of their work. 5 Jobs related to agriculture were deemed essential during pandemic in order to ensure that adequate food and other supplies were available to consumers, and those employed in agriculture faced higher risk of exposure to COVID-19. 6 Several factors may increase the risk of COVID-19 for people in agricultural occupations. Tasks and activities at agricultural workplaces were not interrupted in response to  In the Midwest United States, time-sensitive tasks, such as planting and harvesting continued, even when other businesses temporarily closed or shifted to work-from-home conditions. 1 Production activities, such as planting and harvesting, may increase the risk of COVID-19 transmission. Additionally, many agricultural producers and workers reside in rural areas, where rates of chronic diseases are higher. [7][8][9][10][11] Furthermore, in the United States, recommendations, use, and beliefs in effectiveness of COVID-19 protective behaviors have been contested. Skepticism in science, 12 belief in conspiracy theories, 13 conservative media use, 14 and belief that the risk of COVID-19 had been exaggerated 15

METHODS
This cross-sectional study surveyed agricultural producers and stakeholders from online from April to June 2020 via Qualtrics. Study proce-dures were approved by the University of Illinois Urbana-Champaign

Intitutional Review Board. University of Illinois Extension and Illinois
Farm Bureau shared information about the study in e-newsletters, emails, and social media posts. Eligibility criteria included being age 18 or older, and self-identifying as an agricultural producer, defined as an individual actively engaged in the production of livestock, crops, or other commodities for sale, and/or agricultural stakeholder, defined as an individual whose occupation directly serves agricultural producers. Participants were not compensated for completing the questionnaire. The survey included questions about self-rated physical and mental health, whether participants had chronic health conditions associated with higher severity of COVID-19 (chronic lung disease, severe to moderate asthma, serious heart condition, severe obesity, diabetes, chronic kidney disease, and liver disease), demographic characteristics, and farming/work characteristics. Respondents also indicated their age (≤64 years or ≥65 years), sex (male or female), education level (high school or G.E.D or less; technical, trade, associate degree; bachelor degree or higher), race (white or others), self-employment status (yes, no, prefer not to disclose), and residence (urban, suburban, rural, or other). Respondents were only able to select 1 option for residence.
Definitions for rural, urban, and suburban were not provided.
This article focuses on questions from the survey about perceived effectiveness of and participation in 7 COVID-19 protective behaviors recommended by the Centers for Disease Control and Prevention (CDC; washing hands with soap regularly, disinfecting heavily used surfaces, staying at home as much as possible, practicing social distancing, covering cough or sneeze, wearing a mask, and refraining from touching eyes, nose, and mouth). Respondents indicated on a 3-point Likert scale how effective (not at all effective to very effective) each of the 7 the CDC recommended protective measures are at reducing the spread of COVID-19. Similarly, respondents indicated on a 5-point Likert scale how often (never to every day) they practiced each of the 7 CDC-recommended protective behaviors in the previous 2 weeks.

Sample
Our sample consisted of 1,441 respondents who were mostly white (98%), men (82%), self-employed (74%), resided in rural areas (89%), and identified as agricultural producers (85% is a major producer of soybeans, corn, and pigs, and agriculture contributes over 50 billion dollars to the state's economy annually. 16 Approximately 6% of [State]'s workforce is in agriculture, as agriculture employs nearly 450,000 individuals, including 116,417 agricultural producers. 17 The sample of the current study is very similar to the agricultural producer population in the United States, which is 95% white, majority men (64%), and a mean age of 57.5 and is more similar to the producer population in [State], which is 99% white, nearly three-quarters men (71%), and a mean age of 58.0. 17

Statistical analysis
Latent class analysis (LCA) was used to identify homogeneous, mutually exclusive agricultural groups based on perceived effectiveness and reported participation in COVID-19 protective behaviors. LCA is a statistical method to identify clusters of participants based on shared characteristics. 18 Latent classes have been used to identify health behavior patterns within heterogeneous populations, 19 to identify patterns of compliance with behavioral recommendations to contain COVID-19, 20 and perceptions of threat and confidence during COVID-19. 21 LCA was performed using PROC LCA in SAS 9.4. 22 Separate LCA for perceptions and practices of COVID-19-related protective behaviors was conducted. We fitted LCA models from 2 to  23 We used the P-value of .25 in the bivariate association as the cutoff for statistical significance for inclusion of covariates in the model.

RESULTS
Through LCA, we were able to determine distinct clusters based on participant responses to perception of effectiveness and practice of specific COVID-19 protective behaviors. Based on fit indices (CAIC and BIC), parsimony, and interpretability, 5 clusters for perceptions of effectiveness and 3 clusters for practice of COVID-19 protective behaviors were identified (Table 1 and Table A1). Based on group responses to survey questions, we provided these cluster labels for perception of effectiveness: (1) universal believer; (2)

Perceptions of effectiveness of COVID-19 protective behaviors
The largest cluster comprised of 33% of producers and stakeholders who predominantly perceived that all the COVID-19 protective measures are very effective (universal believer). A very significant distinction of this cluster from the others is that the majority of universal believers said wearing a face mask is very effective. The second largest cluster (26%) of producers and stakeholders were primarily those who considered personal measures (washing hands, disinfecting, refrain from touching the face, and cover cough and sneeze) are very effective but believed social measures (staying home, social distancing, and wearing a face mask) are only somewhat effective (personal believers). The third cluster comprised of 16% of producers and stakeholders, where the majority perceived social measures, such as staying home and social distancing, to be very effective (social believers). Large proportions in this cluster also perceived certain personal measures (washing hands and covering cough and sneeze) to be very effective.
Other COVID-19-related personal preventive measures and wearing a face mask were rated as only somewhat effective by most social believers. The fourth cluster of producers and stakeholders (17%) considered all COVID-19 protective behaviors as only somewhat effective. We referred to them as moderate believers. The fifth and smallest cluster (8%) are described as social skeptics who greatly perceived social measures as ineffective and personal measures as only somewhat effective except for covering cough and sneeze (Table A1).

Practices of COVID-19 protective behaviors
LCA of COVID-19 preventive practices showed 3 clusters as the best fit based on both CAIC and BIC indices. When asked how often they practiced COVID-19-related protective behaviors in the past 2 weeks, the largest cluster of producers and stakeholders (45%) were in the TA B L E 1 Distribution of agricultural producers and stakeholders according to membership in participation in COVID-19 protective behaviors cluster, by membership in perception of effectiveness cluster Over-all χ 2 =434.54 (P<.0001) risk-averse or high adherence group. The majority in this group reported that they observed all personal and social measures every day and always wore a face mask when going out in public. In contrast, 15% of participants are described as low adherents. Over half of this group reported that they never practiced disinfecting surfaces, refraining from touching their face, or wearing face masks. The majority of producers and stakeholders in this group either never stayed at home or only for a few days in the past 2 weeks. However, washing hands and covering cough and sneeze was practiced by most producers and stakeholders in this cluster. The third group comprising of 40% producers and stakeholders are labeled as moderate adherents. Washing hands, refraining from touching their face, covering cough and sneeze, social distancing, and staying at home were reported to be practiced daily or for most days in the past 2 weeks. However, the majority said they practiced disinfecting for half of the days or less. Only 20% always wore a face mask when in public and the rest did so half of the time or less (Table A1).

Measurement invariance of latent classes
We compared fit indices of free-parameter models and measurement invariant models across categories of gender, age, occupation, self-employment, residence (urban-rural), and presence/absence of underlying health conditions. Based on BIC, the measurement invariant models provided a better fit of the data (Table A2). This result meant that the latent classes have similar interpretations in the different subgroups.

Association between perceptions of effectiveness and practices of COVID-19 protective practices in the past 2 weeks
We categorized each producer and stakeholder to the perception of effectiveness and practice cluster where they are most likely to be a member as determined by Bayesian posterior probabilities. The entropy for the LCA models was 0.78 for perception of effectiveness and 0.74 for practice. These values are near 0.8, a widely accepted level entropy value for good fit. 24 We found that the ALCPP was 0.867 for perception of effectiveness clusters and 0.879 for participation clusters. These results indicated that the individuals were most likely grouped into the correct clusters using maximum-probability assignment. Chi-square tests showed a significant association between perceptions of effectiveness and use of protective practices (P<.0001).
While 72% of universal believers were in the high adherence group, only 40% of personal believers, and 46% of social believers were in the high adherence group. Comparatively, 50% of personal believers, 44% of social believers, and 54% of moderate believers were in the moderate adherence group. Last, 59% of social skeptics were in the low adherence group ( Table 2).

Association of perceptions of effectiveness and practices of COVID-19 protective behaviors in the past 2 weeks with demographic characteristics, work factors, and health conditions
While the association of perceptions of effectiveness of COVID-19 protective behaviors was found to be statistically significant with sex (P<.0001), occupation (P=.0122), age (P<.0001), and having diabetes (P=.0014) ( Chi-square was calculated after excluding the "Other" category in Residence and "Prefer not to disclose" in self-employed. to the responsibility for others' wellbeing. 26,27 Other studies using LCA related to COVID-19 protective behaviors have also found 3 groups related to adherence or compliance, of high; public, mixed, or moderate; and low. 20,28,29 Our study confirms that those who had strong beliefs in the effectiveness of protective behaviors were less likely to be in a low adherence group. 28  Across all 3 adherence groups, washing hands and covering cough were among the protective measures most reported. This aligns with findings from Germany that even individuals in a low compliance group participated in covering a cough or sneeze. 20 These behaviors are often communicated and encouraged annually during influenza seasons and commonly practiced among adults in the United States. 32,33 Wearing a face mask yielded the most disagreement between the adherence groups. About 60% of agricultural producers and stakeholders in the high adherence group reported wearing a face mask every day, whereas less than 10% of producers and stakeholders in the low adherence group reported wearing a face mask with the same consistency. Despite their effectiveness in reducing the spread of COVID-19, many people in the United States have been resistant to wearing face masks, 34 and rural residents are much less likely to do so. 35 Women and individuals 65 years of age or greater were more likely to be in the high adherence group. These trends have been observed in previous studies of COVID-19 protective behaviors, where women were more likely to be wearing masks than men. 36 Norms related to masculinity and demonstrating toughness have driven men to be more resistant to wearing face masks. 37

Strengths and limitations
This study had several strengths. LCA allowed us to identify group- Results from this study should be interpreted considering some limitations. Results were drawn from a convenience sample of agricultural producers and stakeholders recruited through agricultural organizations and commodity interest groups. A response rate could not be calculated due to this passive recruitment strategy. Given these 2 conditions, we cannot assume the results are generalizable to the broader agricultural population; however, the demographics of the sample are similar to that of the agricultural producer population in the United States. 17 Participants were not provided a definition for rural, and designation from participants was based on their perception of residential environment and not a definition by USDA or the US Census Bureau.
Additionally, distribution of the clusters derived in this study may not be same for the entire population of agricultural producers and stakeholders, and it is possible that other clusters would be obtained with a representative sample. As a cross-sectional study, we are only able to report correlations and associations between variables rather than causal relationships. Another limitation is that behaviors were selfreported and may have reflected social desirability bias. 49 There are many potential influences on the use of COVID-19 protective practices and perceptions of effectiveness, which we did not include in our survey, such as personal experience with COVID-19 (e.g. self, family, and friends), clarity around best practices for prevention, and social pressures that regulate behavior in public.
Data collection occurred from April to June of 2020. It is unknown whether agricultural producers' and stakeholders' perceptions of effectiveness of COVID-19 protective behaviors and participation in protective behaviors have changed over time. Liao et al repeated cross-sectional surveys and observed consistent latent classes over time, but an increase in public vigilance throughout an epidemic. 50 An additional line of inquiry is if and how individuals move across latent classes. Interventions to encourage individuals to move from low adherence groups to moderate or high adherence groups could be tested and have significant public health benefits.

Conclusion
Overall, our results demonstrate varying levels of compliance with recommended COVID-19 protective behaviors, and that such behaviors are associated with their perceived effectiveness and several demographic characteristics.